306005154-11-6-2024-22-AS-SSAS-DAYQ4L-20241113105028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005154
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:22:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240823121915

FACILITY NAME:	NEWPORT BEACH MEMORY CARE		FACILITY NUMBER:	306005154
ADMINISTRATOR:	SANCHEZ, EILEEN		FACILITY TYPE:	740
ADDRESS:	1000 HALYARD		TELEPHONE:	(949) 220-9700
CITY:	NEWPORT BEACH	STATE: CA	ZIP CODE:	92663
CAPACITY:	42	CENSUS: 30	DATE:	11/06/2024
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Chad Sisco, Operations Manager		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff does not provide care and supervision resulting in multiple falls

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility front desk staff after introducing himself and stating the purpose of the visit.

An initial investigation visit took place on August 30, 2024. During the visit, LPA accompanied by facility staff toured the first floor of the facility as well as the unit where resident R1 is typically located. R1 was in the process of being discharged from the hospital after being sent out to be assessed on the morning of the visit due to a medical episode. LPA requested and reviewed resident and hospice records for R1 and interviewed one staff on duty. Additional witness interviews with hospice staff and R1's attorney-in-fact were conducted via telephone after the initial visit.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240823121915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NEWPORT BEACH MEMORY CARE	FACILITY NUMBER: 306005154
	VISIT DATE: 11/06/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099
During the present visit, LPA conducted a tour of the memory care ground level and reviewed the unit shared by R1 and another resident. Additional hospice and facility records for R1 were requested and reviewed during the visit.

Regarding the allegation that Staff does not provide care and supervision resulting in multiple falls, the following has been concluded: Resident R1 has been admitted to the facility since May 30, 2023. The latest physician report for R1 is dated July 17, 2024 and shows a primary diagnosis of unspecified dementia along a secondary diagnosis of "Other abnormalities of gait and mobility". Based on interviews and incident reports reviewed, R1 sustained multiple fall incidents reported on June 11, 2023 as well as September 3, 2023, August 15, 2024, August 23, 2024 and September 9, 2024. Interviews and records reviewed also showed that R1 had been admitted to receive hospice care on August 28, 2024. Staff in-service training on fall prevention was provided on August 23, 2024. Precautionary measures such as a lowered bed with full rails, rail pads, floor pads and bed alarms have been implemented alongside a plan of care ensuring that R1 is transferred out of bed and placed either in their wheelchair or recliner in the facility's common areas. No further fall incidents have been reported since these precautions have been put in place. During the present visit, R1 was observed to be positioned in one of the recliners in the facility's common areas, as described in the hospice plan of care.

As a result, the allegation is found to be Unsubstantiated, meaning that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024

LIC9099 (FAS) - (06/04)

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